Provider First Line Business Practice Location Address:
915 S. HORTON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-0510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-0210
Provider Business Practice Location Address Fax Number:
620-223-0244
Provider Enumeration Date:
04/05/2006